Government issued Picture ID - Copy of front and back of Driver's License or IDAddress needs to match permanent address above

Waiver and Release of Liability Form - Signed and dated

VOLUNTARY DISCLOSURE CONSENT: I hereby certify that the above information is correct and I further agree that the information may be verified through direct contact with the records bureau at the location of my birth or through the U.S. Immigration and the Naturalization Service. Falsification of documentation shall result in denial of membership.

I acknowledge that softball or any sporting event is an extreme test of a person’s physical and mental limits and carries with it the potential of death, serious injury, or property loss.

I HEREBY ASSUME THE RISKS OF PARTICIPATION IN A SOFTBALL EVENT.

I hereby take the following action for myself, my executors, administrators, heirs, next of kin, successors and assigns:

a) I waive, release, and discharge from any and all claims of liability for death or personal injury or damages of any kind all representatives of the Florida Half Century Amateur Softball Association, Inc.

b) I agree not to sue any representative of the Florida Half Century Amateur Softball Association, Inc. or the association for any claims or liabilities that I have waived, released, or discharged herein.

c) I indemnify and hold harmless the persons or entities mentioned above from any claims made or liabilities assessed against them as a result of my actions.

BY SIGNING THIS FORM, I AFFIRM THAT I AM FIFTY (50) YEARS OF AGE, OR WILL ATTAIN THAT AGE DURING THIS CALENDAR YEAR, OR OLDER, AND THAT I WILL OBEY THE RULES, REGULATIONS AND BYLAWS OF THE ASSOCIATION. I HAVE READ THIS DOCUMENT AND UNDERSTAND ITS CONTENTS.

Printed Name

Date

Signature of Applicant

PLEASE COMPLETELY FILL OUT THE ABOVE FORM LEGIBLY (Typing Preferred) AND MAIL TO:

Mike Knowles

3806 30th Lane E

Bradenton, FL 34208

941-725-0790

PLEASE COMPLETELY FILL OUT THE ABOVE FORM LEGIBLY (Typing Preferred) AND MAIL TO: